Left coronary artery-left ventricle fistula with right coronary artery spasm

A 72-year-old woman was admitted to our hospital for evaluation of chest pain. Coronary angiography showed a left coronary artery-left ventricle fistula. An acetylcholine provocation test induced vasoconstriction of the right but not the left coronary artery. Her chest pain was not relieved by combined therapy with isosorbide dinitrate, diltiazem and nicorandil. Because of the coronary spasm, beta-blockers could not be used. However, her chest pain was relieved after the administration of a minor tranquilizer. Thus, the patient's chest pain was unlikely to be associated with either the fistula or the coronary spasm.     

Coronary artery fistula between the left anterior descending branch and the left ventricle; a case report (author's transl)]

The rare case of a coronary fistula from the left anterior descending branch to the left ventricle is presented. The 38 year old woman was admitted with homonymous quadrantanopsia and hyperacusis. An abnormal Ecg and a systolic and diastolic murmur of unknown origin were discovered. Cardiac catheterization yielded normal findings. Coronary angiography demonstrated an aneurysma of the dilated left anterior descending coronary artery with a fistulous communication into the left ventricle. This congenital left to left shunt produced a typical mid-diastolic murmur clearly separated from the systolic murmur.     

Acute vascular perforation with shunt formation in the right ventricle after percutaneous transluminal coronary angioplasty. Magnetic resonance tomography and Doppler ultrasound detection of shunt flow

A coronary artery perforation is a rare complication after percutaneous transluminal coronary angioplasty. The therapy will be determined by the hemodynamic failure of the left or right ventricle. A case of a coronary artery perforation with a shunt from the right coronary artery to the right ventricle after coronary angioplasty is reported. The shunt was detected by coronary angiography and confirmed by magnetic resonance imaging and doppler echocardiography.     

Efferent sympathetic and vagal innervation of the canine right ventricle

BACKGROUND: The functional pathways of efferent sympathetic and vagal innervation to the right ventricle (RV) might be important in a variety of disease states that involve the RV wall. The purpose of this study was to investigate those pathways. METHODS AND RESULTS: We determined the effects of phenol and endocardial radiofrequency ablation applied to the RV anterolateral wall and outflow tract on effective refractory period (EPR) shortening during bilateral ansae subclaviae stimulation and ERP lengthening during bilateral vagal stimulation. We found that efferent sympathetic axons to the RV are located in the superficial subepicardium and that lateral sites receive sympathetic innervation predominantly from the lateral margin of the RV near the AV groove. Medial sites close to the left anterior descending coronary artery (LAD) receive sympathetic innervation from both the right lateral atrioventricular (AV) groove and regions near the LAD. At the RV outflow tract, some sympathetic fibers are located intramurally. Efferent vagal fibers are located at the RV surface within 10 mm of the right lateral AV groove; they penetrate intramurally and reach to the medial sites of the RV anterior wall. Other vagal fibers originate near the LAD and are intramural. Vagal fibers to the RV outflow tract are located intramurally either from the lateral side (close to the right coronary artery) or medial side (close to the LAD). CONCLUSIONS: Efferent vagal and sympathetic innervation of the right ventricle resembles that of the left ventricle. A major difference is that efferent sympathetic fibers to the right ventricular outflow tract are located not only in the subepicardium but in the subendocardium as well.     

In vitro hydrolysis of gliadin and casein peptides: secondary defect in coeliac disease shown by organ culture

The authors examined whether there is any correlation between the regression speed of cardiac beta (V3)-myosin heavy-chain (MHC) isozyme and duration of overload. The results showed that in the right ventricle of a 1-week overloaded group, the loaded ventricular MHC isozyme V3 (29 center dot 0 +/- 5 center dot 0%, P < 0 center dot 05) returned to the control level within 1 week after relief of overload (20 center dot 4 +/- 4 center dot 2%, P = NS), whereas in a 3 week overloaded group (32 center dot 8 +/- 5 center dot 3%, P < 0 center dot 05) it took 10 weeks (36 center dot 6 +/- 8 center dot 6%, P = NS). The left ventricle showed the same tendency as the right ventricle. In sham-operated rats, however, the changes in MHC isozyme V3 in the left ventricle were greater than those in the right ventricle. These results suggest that regression speed of the cardiac MHC isoform, changed by pressure overload, is accompanied by the duration of overload. Furthermore, the right and left ventricles may have different responsiveness to MHC isoform transitions in heart stresses.     

Ruptured aneurysm of the sinus of Valsalva into the left ventricle: a case report and review of the literature

This report describes a case of right coronary sinus of Valsalva aneurysm which ruptured into the left ventricle. The diagnosis was made with two-dimensional transthoracic echocardiography which showed an abnormal structure extending from the aortic root into the left ventricle adjacent to the interventricular septum. Subsequent examinations with transesophageal echocardiography and aortic root angiography and surgical findings confirmed the diagnosis of transthoracic echocardiography. The patient underwent aortic valve replacement. At follow-up 12 months later, the patient was without symptoms and repeated echocardiographic examinations showed no recurrence.     

Integrity of the pericardium. Its beneficial effects on the protection of the right ventricle in the presence of acute pulmonary hypertension

After cardiac transplant (CT), the right ventricle can be subject to an acute pressure overload, especially in cases where there is a pre-existing severe pulmonary hypertension. Objectives: To determine the maximum tolerance of the right ventricle (MxTRV) when faced with acute pressure overload. To study the function of both ventricles of the healthy heart (donor) when faced with different degrees of pulmonary hypertension. To detect possible interactions between the ventricles in the absence of the pericardium to approximate the experimental model to the clinical model of CT. Methods: The pulmonary artery is progressively constrained in an experimental model until biventricular failure is detected. This experiment is performed in two different situations: with and without pericardial integrity. Results: When pericardial integrity is maintained the MxTRV faced with a pressure overload is 73.2+/-8.56 mmHg. When this pressure is exceeded there is a circulatory collapse with a sharp fall in the cardiac output and in the aortic pressure. However, when pericardectomy is performed (model similar to CT), only 52+/-6.71 mmHg is tolerated (p< 0.001). Conclusions: With the pericardium open, as in CT, the maximum pressure that the right ventricle can support is significantly less than with the pericardium closed. The pericardium has a positive effect in protecting the systolic ventricular interaction.     

Right ventricular function: physiological and physiopathological features

Sinus and conus constitute the two cavities of the right ventricle. They are anatomically and functionally different. The sinus is a flow-generator and the conus a pressure-regulator. The coronary circulation of the right ventricle is provided by the right coronary artery and the left anterior descending artery. The right ventricle is perfused during systole and diastole. When oxygen demand increases, coronary arteries dilate and oxygen extraction rises. As for the left ventricle, right ventricular performance depends upon heart rate, rhythm, contractility and loading conditions. Ventricular interactions are very important for right ventricular function. Loading conditions and contractility of the left ventricle are of major significance for right ventricular performance. For the right ventricle, the end of the ejection is different from the end of the active contraction. The time between them allows to achieve ventricular emptying. This duration is linked to afterload. Presently, it is impossible to accurately and simply assess these conditions. Pressure and volume overloadings result in right ventricular failure. They are responsible for ventricular dilation and ischaemia with a decrease in cardiac output, generating a vicious circle. Treatment includes the removal of the cause, and the maintenance of systemic arterial pressure and biventricular contractility. It is difficult to assess the effects of intravenous vasodilators on right ventricular afterload.     

Double outlet right ventricle with L-position of the aorta, D-loop, subaortic VSD, and pulmonary stenosis

We describe a case of double outlet right ventricle with subaortic ventricular septal defect and pulmonary stenosis treated successfully with cardiopulmonary bypass. We consider the clinical history and angiocardiographic and surgical findings of this rare anomaly. We stress the difficulties of reconstruction of the outflow tract of the right ventricle, because of the anomalous pathway of the right coronary artery, the posterior situation of the pulmonary artery, and the abnormal anatomy present in the outflow tract of the right ventricle.     

Double-chamber right ventricle: a case report

The double-chamber right ventricle is a congenital cardiac malformation usually associated with other cardiac defects, seldom isolated and in adult subject. It is characterized by the presence of an anomalous bundle that divides the right ventricle into two chambers. The clinical and electrocardiographic signs of isolated double-chamber right ventricle are few and not specific. An echocardiographic diagnosis of isolated double-chamber right ventricle is reported. In a 18-year-old asymptomatic male with systolic murmur 2/6 at third space over the left sternal border, right ventricular hypertrophy and intraventricular conduction delay at ECG, two-dimensional echo showed an anomalous transversal muscle bundle that divided the right ventricle into two chambers, superior and inferior. Color Doppler showed a diastolic tricuspidal-like flow through a paraseptal discontinuity of the bundle and a systolic jet that reached the right atrium, with a pressure gradient of 30.9 mmHg. The absence of symptoms and other cardiopathy, without significant right outflow tract obstruction, was considered as an index of a good prognosis; therefore cardiac catheterization was not advised.     

Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function

This article reviews diastolic and systolic ventricular interaction, and clinical pathophysiological conditions involving ventricular interaction. Diastolic ventricular interdependence is present on a moment-to-moment, beat-to-beat basis, and the interactions are large enough to be of physiological and pathophysiological importance. Although always present, ventricular interdependence is most apparent with sudden postural and respiratory changes in ventricular volume. Left ventricular function significantly affects right ventricular systolic function. Experimental studies have shown that about 20% to 40% of the right ventricular systolic pressure and volume outflow result from left ventricular contraction. This dependency of the right ventricle on the left ventricle helps to explain the right ventricular response to volume overload, pressure overload, and myocardial ischemia. The septum and its position are not the sole mechanism for ventricular interdependence. Ventricular interdependence causes overall ventricular deformation, and is probably best explained by the balance of forces at the interventricular sulcus, the material properties, and cardiac dimensions.     

Coronary artery perforation repair using microcoil embolization

An 82-year-old woman undergoing percutaneous transluminal coronary angioplasty experienced perforation of the terminal portion of the left anterior descending coronary artery caused by guidewire trauma. The coronary artery perforation was successfully closed using a vascular occlusion system consisting of individual thrombogenic coils delivered to the site. Coronary artery perforation (CAP) during percutaneous transluminal coronary angioplasty (PTCA) has been reported to occur in less than 1% of cases. The incidence seems to be higher with the new interventional devices, e.g., DCA, TEC, and laser CAP may result in pericardial hemorrhage and cardiac tamponade or a coronary artery fistula to either the left or right ventricle. The management of CAP may include prolonged balloon inflations, reversal of anticoagulation, pericardiocentesis, and emergency surgery. Proximal perforations sometimes can be managed with vein covered stents. We describe another option in the treatment of distal CAP using a vascular occlusion system.     

Adenosine-sensitive ventricular tachycardia from the anterobasal left ventricle

OBJECTIVES: This study demonstrates that exercise-provocable tachycardia resembling right ventricular outflow tract tachycardia may originate from the anterobasal left ventricle. BACKGROUND: Reentry is the operative mechanism of idiopathic left ventricular tachycardia, with a QRS complex of right bundle branch block and superior axis that is responsive to verapamil but not adenosine. Whether some mechanism other than reentry is operative in some idiopathic left ventricular tachycardias is unclear. METHODS: In 4 of 53 consecutive patients with idiopathic left ventricular tachycardia, the tachycardia was sensitive to adenosine. These four patients were women 63, 61, 61 and 31 years old and were the subjects of the present study. RESULTS: In all four patients, spontaneous tachycardia was related to exercise or emotional stress. The tachycardia displayed atypical left (one patient) or right (three patients) bundle branch block with an inferior axis and marked variation in cycle length. An intravenous bolus of adenosine triphosphate (10 to 20 mg) terminated tachycardia in all four patients. Tachycardia was terminated or prevented in three patients given intravenous or oral verapamil. Atrial or ventricular incremental or extrastimulus testing induced tachycardia in all four patients (three with, one without isoproterenol infusion). Electrically induced tachycardia also demonstrated marked variation in cycle length, which ranged from 230 to 390 ms. Entrainment was not demonstrable with overdrive pacing from multiple sites. Endocardial mapping during tachycardia revealed that the earliest activations were registered 25, 40, 35 and 50 ms before onset of the QRS complex, respectively, from the anterior aspect of the left ventricle just below the mitral annulus, adjacent to the left ventricular outflow tract. High frequency Purkinje spikes were not recorded at this site. Radiofrequency current delivered to this site successfully ablated the tachycardia in three of the four patients. CONCLUSIONS: Exercise-provocable, catecholamine-mediated, verapamil-responsive, adenosine-sensitive ventricular tachycardia may arise from the anterobasal left ventricle adjacent to the outflow tract.     

Gross anatomy of the cardiac blood vessels in the North American beaver (Castor canadensis)

The cardiac arteries and veins are described in the North American beaver (Castor canadensis) following the injection of the vessels of 15 hearts with either latex, vinyl plastic or barium sulfate. The left coronary artery gives off the typical circumflex and paraconal interventricular branches which supply the left atrium and ventricle and part of the right ventricle and interventricular septum. The right coronary artery vascularizes the right atrium and ventricule and by means of its subsinuosal interventricular branch, part of the left ventricle and interventricular septum. The paraconal interventricular branch of the left coronary artery lies within the myocardium and is not visible on the surface of the heart. There are no intercoronary anastomoses between the right and left vessels. The major cardiac veins open into the terminal end of the left cranial vena cava. Unlike the arteries, there are venous anastomoses interconnecting the great cardiac vein and the middle cardiac vein. It is concluded that the cardiac blood vessels in Castor canadensis are typically mammalian and resemble those of both land and aquatic mammals.     

Coronary artery fistulae without audible murmur in adults

Retrospective analysis of 4886 adults undergoing coronary arteriography for evaluation of angina between October 1988 and December 1991, revealed coronary artery fistulae in eight patients (all men, aged 36-69 years). No murmur was audible in any of these eight patients. Associated significant coronary artery disease was detected in five patients. The feeder arteries to the fistula were both the left main coronary artery and the left anterior descending artery (LAD) in two, the LAD in six, and the right coronary artery in two patients. The fistula terminated in the pulmonary artery in seven patients and in the right atrium in one patient. Successful operative treatment (coronary artery bypass grafting and ligation of the fistula) was undertaken in four patients with severe obstructive coronary artery disease with satisfactory results. Follow-up for up to 2 years of the three patients with coronary artery fistula and no associated coronary artery disease who did not undergo surgery revealed continuing good prognosis. We conclude that coronary artery fistula in adults is a distinct, though rare (incidence in present series 0.11%) entity, without audible murmur, commonly associated with coronary artery obstructive disease, and that the diagnosis is mostly incidental during routine coronary arteriography.     

Temperature of the sclera during diathermocoagulation carried out in patients with retinal detachment

Regional coronary blood flow was measured by injecting radioactive microspheres (15 mum +/- 5 in diameter) into the left atrium of anesthetized ponies with surgically prepared open thorax before and during occlusion of the coronary arteries. The normal blood flow to the myocardium of the interventricular septum and the left ventricular wall were highest, followed in decreasing order by the right ventricular wall, the interatrial septum, the atrial walls, and the valves. Measurement of transmural blood flow in the normal left ventricle yielded a mean endocardial/epicardial flow ratio of 1.36 in the free wall. The left ventricular flow ratio was 1.33 in the septal wall. The percentage of the left ventricular myocardium made ischemic during occlusion of the right coronary artery or of the left coronary artery (cranial descending and circumflex arteries) was approximately equal. Blood flow to the ischemic areas of the left ventricle after occlusion of coronary arteries ranged from 3.8 to 20.6% of the normal flow. A disproportionate decrease in flow to the endocardial regions of the left ventricle was also observed in ischemic areas (mean inner/outer left ventricular wall flow ratio was 68.89% of the normal flow ratio).     

Configuration of linear dynamic cardiomyoplasty for hypoplastic right ventricle

BACKGROUND: The purpose of this study is to determine feasibility of linear dynamic cardiomyoplasty with a briefly preconditioned latissimus dorsi in the experimental model simulating patch enlargement of the hypoplastic right ventricle. METHODS: In 8 mongrel dogs, a diminished right ventricular chamber was reconstructed with an extended pericardial patch. A left latissimus dorsi, preconditioned for 2 weeks (2 Hz) after a previous 2-week vascular delay period, was placed on the patch, with the muscle fiber oriented in parallel to the right ventricular long axis. RESULTS: Graft pacing with trained-pulses of 25 Hz at a 1:1 ratio showed significant augmentation of pulmonary flow and pressure (158% +/- 21%, 156% +/- 14%, respectively), contributing to restoring right ventricular function comparable with preoperative control, which was also confirmed by the right ventricular function curve and pressure-volume relationship analyzes. Continuous pacing was performed in 4 animals for 7 hours without evidence of muscle fatigue, implying feasibility of "working conditioning" after minimum preconditioning for this type of right heart assist. CONCLUSIONS: Linear latissimus dorsi myoplasty can restore normal right ventricular performance at a physiologic preload, and may provide a surgical option for the hypoplastic right ventricle.     

A case of total cavopulmonary connection with preceding tricuspid valve closure in pulmonary atresia and intact ventricular septum, right ventricular-coronary artery fistulae, and coronary artery stenoses]

More than half of the patients with pulmonary atresia and intact ventricular septum (PA/IVS) are known to complicate right ventricular-coronary artery fistula (fistulae) and particularly those with coronary artery stenoses bear a high mortality rate and remain in a surgical challenge. A 4-year-old girl was first admitted to our hospital at 5 days of age and right ventriculogram revealed markedly hypoplastic tripartite ventricle and multiple fistulae through which both coronary arteries and aortic root were retrogradely opacified. Echocardiographically measured diameter of the tricuspid valve was 5 mm (Z value: 4). She underwent pulmonary valvotomy and central aorto-pulmonary (AP) shunt at 16 days of age. Repeat right ventriculogram at 1.9 years of age disclosed multiple stenoses in left anterior descending coronary artery (LAD) with proximal dilatation and tortuosity. Additional findings of left ventricular dysfunction (LVEF of 61.5%) and depressed ST segment in left precordial leads prompted us to proceed to the second palliation which comprised take-down of central AP shunt, bidirectional cavopulmonary shunt and closure of tricuspid and pulmonary valves. Catheterization at 3.4 years of age disclosed antegradely filled LAD with apparent relief of stenoses and improvement of LVEF to 68.9%. She underwent definitive repair of total cavopulmonary connection at 4.0 years of age and is leading a normal life 2 years after surgery. This experience draws us to conclude that tricuspid valve closure is a meaningful palliative procedure for PA/IVS with fistulae and coronary artery stenoses, provided that proximal segments of both coronary arteries remain intact.     

Percutaneous closure of congenital and iatrogenic coronary arterial fistulas

Coronary arteriovenous fistulas (CAF) are the most common hemodinamically significant congenital coronary anomalies. Surgery has been the only therapeutic option for ages. We describe three cases of percutaneous occlusion of CAF, congenital and iatrogenic, that we treated with different devices, to fit their different anatomic and functional characteristics. Case 1). Male patient (pt) 20 years old, asymptomatic, affected with CAF between the right coronary artery and the right ventricle, with aneurysmatic vessel dilatation and occlusion of the posterolateral branches. CAF has been occluded with a detachable, valvulated latex balloon, wedged into the proximal neck of the aneurysm. Case 2). Female pt 63 years old, who was symptomatic for exertion angina, affected with multiple CAF which originated from proximal and distal circumflex artery, proximal left anterior descending artery (LAD), all of which flowed into the left inferior lobar pulmonary artery. The fistulas have been occluded with steel and tungsten coils. Case 3). Male pt 62 years old, who underwent orthotopic cardiac transplantation in 1990 for dilated cardiomyopathy. Coronary angiogram at one year was normal, but subsequently a multilocular CAF between LAD in the middle portion and the right ventricle became evident. During angiographic follow-up an increase of the size of the fistula was observed, together with a reduction of that of distal LAD. For this reason a percutaneous occlusion with multiple tungsten coil has been performed. The three procedures have had a favorable outcome and we did not observe any acute or late complications; clinical and angiographic follow-up confirmed this satisfactory results at six months. Based on the data of the literature and on this experience, we conclude that percutaneous occlusion is the first line therapy of CAF and that the different devices can be tailored to meet different anatomic and functional characteristics.     

Isolated congenital diverticulum of the left ventricle disclosed by ventricular tachycardia in a 72-year-old woman

A 72-year-old woman presented with poorly tolerated ventricular tachycardia reduced by intravenous amiodarone. The possibility of an ischaemic aetiology led us to perform coronary angiography. The coronary arteries were pathological. Left ventricular angiography revealed limited anterior hypokinesia and a large contractile apical pouch appended to the left ventricle by a long narrow neck. Despite the appearance suggestive of congenital left ventricular diverticulum (contractility, narrow neck) and because of the coexistence of ischaemic heart disease, we preferred to confirm the muscular nature of the diverticulum by myocardial thallium scintigraphy, which showed reversible decreased uptake in the anterior zone related to coronary artery disease, and confirmed the muscular nature of the diverticulum which showed normal thallium uptake. MRI clearly visualized the ventricular ectasia attached by a narrow neck to the rest the left ventricle. This long narrow neck indicated that this muscular diverticulum constituted a congenital diverticulum. The contribution of ultrasonography was limited by a poorly defined point during the examination. This congenital diverticulum, discover during adulthood, and previously asymptomatic, is a rare lesion, in the light of a review of the literature.